The global HIV epidemic starts to go grey

Joel Negin is a Senior Lecturer in International Public Health and Director of Research at the School of Public Health, University of Sydney, NSW, Australia

Earlier this month, UNAIDS released a long-awaited supplement to its annual epidemic update, focusing on HIV among older adults. For decades, HIV prevalence has been reported only on the basis of data for those aged 15–49 years, a hangover of the fact that much early data collection was through antenatal care sites and through demographic and health surveys focused on maternal and child health. Those living with HIV aged 50 years and older were consequently ignored and neglected.

Over the past few years, a small group of researchers and advocates have taken to heart Phillip Setel’s passionate exhortation to “make everyone count by counting everyone” and have started to gather data on HIV in older adults (as those aged 50 years and older are most often called). Multiple estimates have put the number of people living with HIV aged 50 and older in sub-Saharan Africa at 3 million.

The ageing of the HIV cohort in Africa mirrors what has been seen in developed countries; in the USA, by 2015, 50% of people living with HIV will be aged 50 years or older. This is a by-product of the success of antiretroviral treatment (ART), with those on treatment regaining near-normal life expectancy. As new infections decline (partly due to treatment access) and those living with HIV live longer, the ageing of the HIV cohort is an unavoidable reality.

What are the implications of the ageing of the HIV cohort? First of all, most prevention messaging over the past decade has been targeted to adolescents and young adults. Because more and more of those living with HIV are older, it is time to adapt prevention tools and messages to older adults. Despite ongoing ageist stigma, older adults are still sexually active. At the same time, levels of awareness and HIV-related knowledge are significantly lower among older adults. In the field, most counsellors working on voluntary counselling and testing programmes are relatively young. That means a reality of 60-year-old women talking to 22-year-old men about sexual behaviour and attitudes – perhaps not the best model for appropriate and age-friendly services.

In most developing countries, older adults are more likely to live in rural areas, to be poor, and to have less access to health services. This limits their access to treatment. However, in some ART cohorts, 15% or more of those on treatment are aged 50-plus. For older adults, timely initiation of ART is critical because their immune systems seem to recover more slowly than those of younger adults. More can be done to target older adults specifically to ensure their access to treatment and to support their adherence. Travel vouchers, older adult peer support groups, and improved messaging could help to end the neglect of older adults.

One of the emerging and critical realities of ageing with HIV is co-morbidities. As people age, they are more likely to have chronic conditions such as diabetes, angina, arthritis, and stroke. This is especially true for those living with HIV. As the HIV cohort ages, these comorbidities will have profound impacts on developing country health systems, which will have to address a double burden.

Despite these epidemiological, preventative, and clinical challenges, it has taken to late 2013 for the acknowledgement of the ageing of the epidemic in developing countries. Fundamentally, the fact is that 50 is not that old! Many of our community leaders, business people, politicians, teachers, family, and friends are over 50. The current situation of not even counting them as part of the epidemic was clearly inappropriate and unsustainable.

A bit of grey hair makes one look distinguished – it is time for the global HIV community to stop dying its hair and embrace its ageing. Older adults need to be included in the measurement of the epidemic as well as in its response – as actors, stakeholders, and leaders. I am encouraged by UNAIDS’s supplement and hope that it is a harbinger of greater attention to this issue by policymakers and researchers alike.

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